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FamilyCareHealthCenters
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Enhance Your Smile with Dental Coverage
Anthem
Dental Complete
Schedule of
Benefits
In Network
Out of Network
Deductible
Individual
Family
$50
$150
$50
$150
Coinsurance
Diagnostic/Preventive
Basic Services
Major Services
100%
80%
50%
100%
75%
50%
Annual Maximum
$1,000/person
See Clearly with Vision Coverage
Anthem Blue
View Vision
In Network
Out of Network
Examination Co-pay
$20
$42 Reimbursement
Frequency of Service:
Exam
Lenses
Frames
Every 12 months
Every 12 months
Every 24 months
Lenses
Single
Bifocal
Trifocal
$20 Co-pay then
100%
100%
100%
Reimbursement
$40
$60
$80
Frames
$130 Allowance, 20% off remaining balance
$45
Contacts
Non-Elective
Elective Conventional
Elective Disposable
100%
$130 Allowance, plus 15% off remaining balance
$130 Allowance
Reimbursement
$210
$105
Find a dental or additional vision providers by going to
www.anthem.comand clicking on “Find a Doctor”: You will
enter search criteria such as
Blue View Vision
and
Dental Complete
to find providers in Anthem’s Network.
Below is only a few (of many) vision providers in Anthem’s network.